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Simmons C, Pot M, Lorenz-Dant K, Leichsenring K. Disentangling the impact of alternative payment models and associated service delivery models on quality of chronic care: A scoping review. Health Policy 2024; 143:105034. [PMID: 38508061 DOI: 10.1016/j.healthpol.2024.105034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 02/27/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024]
Abstract
Payment reforms are frequently implemented alongside service delivery reforms, thus rendering it difficult to disentangle their impact. This scoping review aims to link alternative payment arrangements within their context of service delivery, to assess their impact on quality of chronic care, and to disentangle, where possible, the impact of payment reforms from changes to service delivery. A search of literature published between 2013 and 2022 resulted in 34 relevant articles across five types of payment models: capitation/global budget (n = 13), pay-for-coordination (n = 10), shared savings/shared risk (n = 6), blended capitation (n = 3), and bundled payments (n = 1). The certainty of evidence was generally low due to biases associated with voluntary participation in reforms. This scoping review finds that population-based payment reforms are better suited for collaborative, person-centred approaches of service delivery spanning settings and providers, but also highlights the need for a wider evidence base of studies disentangling the impact of financing from service delivery reforms. Limited evidence disentangling the two suggests that transforming service delivery to a team-based model of care alongside a purchasing reform shifting to blended capitation was more impactful in improving quality of chronic care, than the individual components of payment and service delivery. Further comparative studies employing causal inference methods, accounting for biases and quantifying aspects of service delivery, are needed to better disentangle the mechanisms impacting quality of care.
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Affiliation(s)
- Cassandra Simmons
- European Centre for Social Welfare Policy & Research, Vienna, Austria.
| | - Mirjam Pot
- European Centre for Social Welfare Policy & Research, Vienna, Austria
| | - Klara Lorenz-Dant
- General Practice, Institute of General Practice, University Hospital of Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Kai Leichsenring
- European Centre for Social Welfare Policy & Research, Vienna, Austria
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Yordanov D, Oxholm AS, Prætorius T, Kristensen SR. Financial incentives for integrated care: A scoping review and lessons for evidence-based design. Health Policy 2024; 141:104995. [PMID: 38290390 DOI: 10.1016/j.healthpol.2024.104995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 01/11/2024] [Accepted: 01/14/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND In response to the increasing prevalence of people with chronic conditions, healthcare systems restructure to integrate care across providers. However, many systems fail to achieve the desired outcomes. One likely explanation is lack of financial incentives for integrating care. OBJECTIVES We aim to identify financial incentives used to promote integrated care across different types of providers for patients with common chronic conditions and assess the evidence on (cost-)effectiveness and the facilitators/barriers to their implementation. METHODS This scoping review identifies studies published before December 2021, and includes 33 studies from the United States and the Netherlands. RESULTS We identify four types of financial incentives: shared savings, bundled payments, pay for performance, and pay for coordination. Substantial heterogeneity in the (cost-)effectiveness of these incentives exists. Key implementation barriers are a lack of infrastructure (e.g., electronic medical records, communication channels, and clinical guidelines). To facilitate integration, financial incentives should be easy to communicate and implement, and require additional financial support, IT support, training, and guidelines. CONCLUSIONS All four types of financial incentives may promote integrated care but not in all contexts. Shared savings appears to be the most promising incentive type for promoting (cost-)effective care integration with the largest number of favourable studies allowing causal interpretations. The limited evidence pool makes it hard to draw firm conclusions that are transferable across contexts.
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Affiliation(s)
- Dimitar Yordanov
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
| | - Anne Sophie Oxholm
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
| | - Thim Prætorius
- Research Unit for Integrated Care and Prevention, Steno Diabetes Centre Aarhus, Aarhus University Hospital, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark.
| | - Søren Rud Kristensen
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
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Brown TT, Hague E, Neumann A, Rodriguez HP, Shortell SM. Impact of a selective narrow network with comprehensive patient navigation on access, utilization, expenditures, and enrollee experiences. Health Serv Res 2023; 58:332-342. [PMID: 36111577 PMCID: PMC10012245 DOI: 10.1111/1475-6773.14066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the effect of enrollee switching from a broad-network accountable care organization (ACO) health maintenance organization (HMO) to a "high performance" ACO-HMO with a selective narrow network and comprehensive patient navigation system on access, utilization, expenditures, and enrollee experiences. DATA SOURCES Secondary administrative data were obtained for 2016-2020, and primary interview and survey data in 2021. STUDY DESIGN Fixed-effects instrumental variable analyses of administrative data and regression analyses of survey data. Outcomes included access, utilization, expenditures, and enrollee experience. Background information was gathered via interviews. DATA COLLECTION/EXTRACTION METHODS We obtained medical expenditure/enrollment and access data on continuously enrolled members in a broad-network ACO-HMO (n = 24,555), a subset of those who switched to a high-performance ACO-HMO in 2018 (n = 7664); interviews of organizational leaders (n = 13); and an enrollee survey (n = 512). PRINCIPAL FINDINGS Health care effectiveness data and information Set (HEDIS) access measures were not different across plans. However, annual utilization dropped by 15.5 percentage points (95% CI: 18.1, 12.9) more in the high-performance ACO-HMO, with relative annual expenditures declining by $1251 (95% CI: $1461, $1042) per person per year. High-performance ACO-HMO enrollees were 10.1 percentage points (95% CI 0.001, 0.201) more likely to access primary care usually or always as soon as needed and 11.2 percentage points (95% CI 0.007, 0.217) more likely to access specialty care usually or always as soon as needed. Plan satisfaction was 7.1 percentage points (95% CI: -0.001, 0.138) higher in the high-performance ACO-HMO. Interviewees noted the comprehensive patient navigation system was designed to ensure patients remained in the narrow network to receive care. CONCLUSIONS ACO and HMO contracts with selective narrow networks supported by comprehensive patient navigation can reduce expenditures and improve specialty access and patient satisfaction compared to broad-network plans that lack these features. Payers should consider implementing narrow networks with comprehensive support systems.
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Affiliation(s)
- Timothy T. Brown
- School of Public HealthUniversity of CaliforniaBerkeleyCaliforniaUSA
| | - Emily Hague
- School of Public HealthUniversity of CaliforniaBerkeleyCaliforniaUSA
| | - Alicia Neumann
- Division of Geriatrics, Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
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Yan Z, Li M, Ni JZ, McFadden KL. Examining network entry decisions in healthcare: Network and organizational characteristics. DECISION SCIENCES 2023. [DOI: 10.1111/deci.12590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Affiliation(s)
- Zhenzhen Yan
- Department of Management, College of Business Idaho State University Pocatello Idaho
| | - Mei Li
- Division of Marketing and Supply Chain Management, Price College of Business The University of Oklahoma Norman Oklahoma USA
| | - John Z. Ni
- Department of Management, Farmer School of Business Miami University Oxford Ohio
| | - Kathleen L. McFadden
- Department of Operations Management and Information Systems, College of Business Northern Illinois University DeKalb Illinois
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Gao J, Moran E, Grimm R, Toporek A, Ruser C. The Effect of Primary Care Visits on Total Patient Care Cost: Evidence From the Veterans Health Administration. J Prim Care Community Health 2022; 13:21501319221141792. [PMID: 36564889 PMCID: PMC9793026 DOI: 10.1177/21501319221141792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Since the 1980s, primary care (PC) in the US has been recognized as the backbone of healthcare providing comprehensive care to complex patients, coordinating care among specialists, and rendering preventive services to contain costs and improve clinical outcomes. However, the effect of PC visits on total patient care cost has been difficult to quantify. OBJECTIVE To assess the effect of PC visits on total patient care cost. METHODS This is a retrospective study of over 5 million patients assigned to a PC provider in the Veterans Health Administration (VHA) in each of the 4 fiscal years (FY 2016-2019). The main outcome of interest is total annual patient care cost. We assessed the effect of primary care visits on total patient care cost first by descriptive statistics, and then by multivariate regressions adjusting for severity of illness and other confounders. We conducted in-depth sensitivity analyses to validate the findings. RESULTS On average, each additional in-person PC visit was associated with a total cost reduction of $721 (per patient per year). The first PC visit was associated with the largest savings, $3976 on average, and a steady diminishing return was observed. Further, the higher the patient risk (severity of illness), the larger the cost reduction: Among the top 10% of high-risk patients, the first PC in-person visit was associated with a reduction of $16 406 (19%). CONCLUSIONS These findings, substantiated by our exhaustive sensitivity analyses, suggest that expanding PC capacity can significantly reduce overall health care costs and improve patient care outcomes given the former is a strong proxy of the latter.
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Affiliation(s)
- Jian Gao
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement,Jian Gao, Department of Veterans Affairs,
Office of Productivity, Efficiency and Staffing, Office of Analytics and
Performance Improvement, 67 Veterans Way, Albany, NY 12208, USA.
| | - Eileen Moran
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement
| | | | - Andrew Toporek
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement
| | - Christopher Ruser
- VACT Healthcare System, Yale University
School of Medicine, New Haven, CT, USA
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Girdish C, Rossini A, Sutton BS, Parente AK, Howell BL. The Longitudinal Impact Of A Multistate Commercial Accountable Care Program On Cost, Use, And Quality. Health Aff (Millwood) 2022; 41:1795-1803. [PMID: 36469827 DOI: 10.1377/hlthaff.2022.00279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The prevalence of accountable care organizations (ACOs) has grown significantly across Medicare and commercial payers in the past decade, but there are limited insights regarding the effect of ACOs on costs in the commercial population. We used longitudinal administrative claims data over the course of nineteen calendar quarters from 2016 to 2021 to assess the ongoing incremental impact of Elevance Health's commercial ACO program on cost and use across fifteen US states. We also analyzed the program's impact on spending subcategories (inpatient, outpatient, professional, and pharmacy) and measured differences in quality performance. The program was associated with incremental savings during this period. Incremental savings were greater in the fully insured population relative to the administrative services only population and were due to outpatient and pharmacy savings. ACO providers had superior quality performance measures relative to contracted providers not participating in ACOs. Payers should be aware of the potential for diminishing marginal returns of ACO contracting on containing health care costs.
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Bunker JN, Mitchell SL, Belanger E, Gozalo PL, Teno JM. Pain Impacting Quality of Life in Persons with Dementia Dying in the Nursing Home by Alternative Medicare Payment Model. J Palliat Med 2022; 25:1795-1801. [PMID: 35675641 PMCID: PMC9784608 DOI: 10.1089/jpm.2022.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 01/04/2023] Open
Abstract
Background: Medicare alternative payment models were created to improve health care value by controlling costs and improving care quality. Objective: To determine if prevalence of pain affecting quality of life (QoL) differs by Medicare payment model among nursing home (NH) decedents with dementia at the end of life. Setting/Subjects: NH decedents in 2017/2018 in the United States with dementia who self-reported pain on a Minimum Data Set assessment in the last 30 days of life. Measurements: Main outcome was pain impacting QoL (i.e., affecting day-to-day activities or sleep). Multivariable logistic analysis examined the association between payment model (traditional Medicare [TM], Medicare Advantage [MA], or accountable care organizations [ACOs]) and pain impacting QoL after controlling for potential confounders. Results: There were 115,757 NH residents with dementia who self-reported pain in the last 30 days of life. Of those, 17.8% (n = 20,585) reported having pain the last five days from assessment, which varied by Medicare payment model (17.7% in TM, 17.5% in MA, and 19.1% in ACOs; p < 0.001). Among decedents reporting pain, 23.6% of ACO decedents reported pain affecting QoL compared to 22.1% in MA and 21.6% in TM (p = 0.09). After adjustment, decedents in ACOs compared to TM had greater predicted probability of pain affecting QoL (absolute marginal difference 0.017, 95% CI 0.00-0.035, p = 0.05), and persons in MA did not differ from persons in TM (absolute marginal difference 0.005, 95% CI -0.008 to 0.019, p = 0.41). Conclusions and Implications: Among dementia decedents dying with pain, pain impacted QoL in more than one in five persons. All payment models can improve pain management.
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Affiliation(s)
- Jennifer N. Bunker
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Susan L. Mitchell
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Emmanuelle Belanger
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Pedro L. Gozalo
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Joan M. Teno
- Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
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Wright JR, Madhusudhan DK, Lawrence DC, Watts SA, Lord DJ, Whaley C, Bravata DM. Costs of Specialist Referrals From Employer-Sponsored Integrated Health Care Clinics Are Lower Than Those From Community Providers. J Gen Intern Med 2022; 37:3861-3868. [PMID: 35882712 PMCID: PMC9321287 DOI: 10.1007/s11606-022-07724-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 06/26/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND There have been very few published studies of referral management among commercially insured populations and none on referral management from employer-sponsored health centers. OBJECTIVE Describe the referral management system of an integrated employer-sponsored health care system and compare specialist referral rates and costs of specialist visits between those initiated from employer-sponsored health clinics and those initiated from community providers. DESIGN Retrospective, comparative cohort study using multivariate analysis of medical claims comparing care initiated in employer-sponsored health clinics with propensity-matched controls having specialist referrals initiated by community providers. PATIENTS Adult patients (≥ 18 years) eligible for employer-sponsored clinical services incurring medical claims for specialist referrals between 12/1/2018 and 12/31/2020. The study cohort was comprised of 3129 receiving more than 75% of their care in the employer-sponsored clinic matched to a cohort of 3129 patients receiving care in the community. INTERVENTION Specialist referral management program implemented by Crossover Health employer-sponsored clinics. MAIN MEASURES Rates and costs of specialist referrals. KEY RESULTS The relative rate of specialist referrals was 22% lower among patients receiving care in employers-sponsored health clinics (35.1%) than among patients receiving care in the community (45%, p <0.001). The total per-user per-month cost for patients in the study cohort was $372 (SD $894), compared to $401 (SD $947) for the community cohort, a difference of $29 (p<0.001) and a relative reduction of 7.2%. The lower costs can be attributed, in part, to lower specialist care costs ($63 (SD $140) vs $76 (SD $213) (p<0.001). CONCLUSIONS Employer-sponsored health clinics can provide effective integrated care and may be able to reduce avoidable specialist utilization. Standardized referral management and care navigation may drive lower specialist spend, when referrals are needed.
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Affiliation(s)
| | - Divya K Madhusudhan
- Crossover Health, San Clemente, CA, USA.,Harvard Medical School Postgraduate Medical Education, Global Clinical Scholars Research Training Program, Boston, MA, USA
| | | | - Sharon A Watts
- Crossover Health, San Clemente, CA, USA.,Watts Writing LLC, Akron, OH, USA
| | | | | | - Dena M Bravata
- Crossover Health, San Clemente, CA, USA. .,Stanford Center for Primary Care & Outcomes Research, Palo Alto, CA, USA. .,, San Mateo, USA.
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To What Extent Are ACO and PCMH Models Advancing the Triple Aim Objective? Implications and Considerations for Primary Care Medical Practices. J Ambul Care Manage 2022; 45:254-265. [PMID: 36006384 DOI: 10.1097/jac.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) have emerged to advance the health care system by achieving the Triple Aim of improving population health, reducing costs, and enhancing the patient experience. This review examines evidence regarding the relationship between these innovative care models and care outcomes, costs, and patient experiences. The 28 articles summarized in this review show that ACO and PCMH models play an important role in achieving the Triple Aim, when compared with conventional care models. However, there can be drawbacks associated with model implementation. The long-term success of these models still merits further investigation.
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Lam MB, Friend TH, Erfani P, Orav EJ, Jha AK, Figueroa JF. ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study. J Gen Intern Med 2022; 37:3275-3282. [PMID: 35022958 PMCID: PMC9550919 DOI: 10.1007/s11606-021-07183-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/28/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending. OBJECTIVE To examine whether practices that became ACOs altered spending and utilization at the EOL. DESIGN Retrospective analysis of Medicare claims. PATIENTS We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. MAIN MEASURES Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation. KEY RESULTS The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. CONCLUSIONS With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.
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Affiliation(s)
- Miranda B Lam
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Radiation Oncology, Brigham and Women's Hospital / Dana Farber Cancer Institute, Boston, MA, USA.
- Harvard Medical School, MA, Boston, USA.
| | - Tynan H Friend
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - E John Orav
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ashish K Jha
- School of Public Health, Brown University, Providence, RI, USA
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Harvard Medical School, MA, Boston, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
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11
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Simon B, Amelung VE. [10 Years Accountable Care Organizations in the USA: Impulses for Health Care Reform in Germany?]. DAS GESUNDHEITSWESEN 2022; 84:e12-e24. [PMID: 35114697 DOI: 10.1055/a-1718-3332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
GOAL OF THE STUDY An intent of the Patient Protection and Affordable Care Acts (ACA), also know as Obama Care, was to slow the expenditure growth in the public Medicare-System by shifting the accountability for health care outcomes and costs to the provider. For this purpose, provider were allowed to form networks, which would then take accountability for a defined population - Accountable Care Organizations (ACOs). Ten years after the introduction of ACOs, this paper looks at the impact of ACOs both on quality of care and costs of care to assess if ACOs can be a model of care delivery for Germany. METHODS In a mixed-method approach, a rapid review was conducted in Health System Evidence and PubMed. This was supported with further papers identified using the snowballing-technique. After screening the abstracts, we included articles containing information on cost- and/or quality impact of US-Medicare-ACOs. The findings of the rapid review were challenged with 16 ACO-experts and stakeholder in the USA. RESULTS In total, we included 60 publications which incorporated 6 reports that were either conducted directly by governmental institutions or ordered by them, along with 3 previous reviews. Among these, 31 contained information on costs of care, 18 contained information on quality of care and 11 had information on both aspects. The publications show that ACOs reduced costs of of care. Cost reductions were achieved compared to historic costs, to populations not cared for in ACOs, and counterfactuals. Quality of care stayed the same or improved. CONCLUSION ACOs contributed to slowing the cost growth in US Medicare without compromising quality of care. Thus, a transferal of this model of care to Germany should be considered. However, various policies have led to ACOs failing to unleash their full potential. Against this background, and against the background of stark differences between US Medicare and the German health care system, a critical reflection of the necessary policies underlying ACOs-like structures in Germany, needs to be undertaken.
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Affiliation(s)
- Benedikt Simon
- Harkness Fellowship, Commonwealth Fund, New York, United States.,Chief Officer Integrated and Digital Care, Asklepios Kliniken GmbH & Co. KGaA, Hamburg, Germany
| | - Volker Eric Amelung
- Institut für Epidemiologie, Sozialmedizin und Gesundheitssystemforschung, Medizinische Hochschule Hannover, Hannover, Germany
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12
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Kahn JG, Sullivan KR. Promise vs. Practice: the Actual Financial Performance of Accountable Care Organizations. J Gen Intern Med 2022; 37:680-681. [PMID: 34389936 PMCID: PMC8858353 DOI: 10.1007/s11606-021-07089-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 07/28/2021] [Indexed: 02/03/2023]
Affiliation(s)
- James G Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA.
| | - Kip R Sullivan
- Advisory Board, Health Care for All Minnesota, Minneapolis, MN, USA
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Coe NB, Ingraham B, Albertson E, Zhou L, Wood S, Grembowski D, Conrad D. The one-year impact of accountable care networks among Washington State employees. Health Serv Res 2021; 56:604-614. [PMID: 33861869 PMCID: PMC8313948 DOI: 10.1111/1475-6773.13656] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To estimate the impact of a new, two-sided risk model accountable care network (ACN) on Washington State employees and their families. DATA SOURCES/STUDY SETTING Administrative data (January 2013-December 2016) on Washington State employees. STUDY DESIGN We compared monthly health care utilization, health care intensity as measured through proxy pricing, and annual HEDIS quality metrics between the five intervention counties to 13 comparison counties, analyzed separately by age categories (ages 0-5, 6-18, 19-26, 18-64). DATA COLLECTION/EXTRACTION METHODS We used difference-in-difference methods and generalized estimating equations to estimate the effects after 1 year of implementation for adults and children. PRINCIPAL FINDINGS We estimate a 1-2 percentage point decrease in outpatient hospital visits due to the introduction of ACNs (adults: -1.8, P < .01; age 0-5: -1.2, P = .07; age 6-18: -1.2, P = .06; age 19-26; -1.2, P < .01). We find changes in primary and specialty care office visits; the direction of impact varies by age. Dependents age 19-26 were also responsive with inpatient admissions declines (-0.08 percentage points, P = .02). Despite changes in utilization, there was no evidence of changes in intensity of care and mixed results in the quality measures. CONCLUSIONS Washington's state employee ACN introduction changed health care utilization patterns in the first year but was not as successful in improving quality.
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Affiliation(s)
- Norma B. Coe
- Department of Medical Ethics and Health PolicyPerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- The Leonard Davis InstituteUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Bailey Ingraham
- Department of Health ServicesSchool of Public HealthUniversity of WashingtonSeattleWashingtonUSA
| | | | - Lingmei Zhou
- Department of MedicineUniversity of Washington School of MedicineSeattleWashingtonUSA
- Value & Systems Science LabUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Suzanne Wood
- Department of Health ServicesSchool of Public HealthUniversity of WashingtonSeattleWashingtonUSA
| | - David Grembowski
- Department of Health ServicesSchool of Public HealthUniversity of WashingtonSeattleWashingtonUSA
| | - Douglas Conrad
- Department of Health ServicesSchool of Public HealthUniversity of WashingtonSeattleWashingtonUSA
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14
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Song Z. Taking account of accountable care. Health Serv Res 2021; 56:573-577. [PMID: 34105147 PMCID: PMC8313947 DOI: 10.1111/1475-6773.13689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 12/28/2022] Open
Affiliation(s)
- Zirui Song
- Department of Health Care PolicyHarvard Medical SchoolBostonMassachusettsUSA
- Department of MedicineMassachusetts General HospitalBostonMassachusettsUSA
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15
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Zhang H, Cowling DW, Graham JM, Taylor E. Impact of a commercial accountable care organization on prescription drugs. Health Serv Res 2021; 56:592-603. [PMID: 33508877 PMCID: PMC8313955 DOI: 10.1111/1475-6773.13626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To determine the long-run impact of a commercial accountable care organization (ACO) on prescription drug spending, utilization, and related quality of care. DATA SOURCES/STUDY SETTING California Public Employees' Retirement System (CalPERS) health maintenance organization (HMO) member enrollment data and pharmacy benefit claims, including both retail and mail-order generic and brand-name prescription drugs. STUDY DESIGN We applied a longitudinal retrospective cohort study design and propensity-weighted difference-in-differences regression models. We examined the relative changes in outcome measures between two ACO cohorts and one non-ACO cohort before and after the ACO implementation in 2010. The ACO directed provider prescribing patterns toward generic substitution for brand-name prescription drugs to maximize shared savings in pharmacy spending. DATA COLLECTION/EXTRACTION METHODS The study sample included members continuously enrolled in a CalPERS commercial HMO from 2008 through 2014 in the Sacramento area. PRINCIPAL FINDINGS The cohort differences in baseline characteristics of 40 483 study participants were insignificant after propensity-weighting adjustment. The ACO enrollees had no significant differential changes in either all or most of the five years of the ACO operation for the following measures: (1) average total spending and (2) average total scripts filled and days supplied on either generic or brand-name prescription drugs, or the two combined; (3) average generic shares of total prescription drug spending, scripts filled or days supplied; (4) annual rates of 10 outpatient process quality of care metrics for medication prescribing or adherence. CONCLUSIONS Participation in the commercial ACO was associated with negligible differential changes in prescription drug spending, utilization, and related quality of care measures. Capped financial risk-sharing and increased generics substitution for brand names are not enough to produce tangible performance improvement in ACOs. Measures to increase provider financial risk-sharing shares and lower brand-name drug prices are needed.
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Affiliation(s)
- Hui Zhang
- Health Policy Research DivisionCalifornia Public Employees' Retirement SystemSacramentoCaliforniaUSA
| | - David W. Cowling
- Health Policy Research DivisionCalifornia Public Employees' Retirement SystemSacramentoCaliforniaUSA
| | - Joanne M. Graham
- Health Policy Research DivisionCalifornia Public Employees' Retirement SystemSacramentoCaliforniaUSA
| | - Erik Taylor
- Health Policy Research DivisionCalifornia Public Employees' Retirement SystemSacramentoCaliforniaUSA
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Abstract
Accountable care organizations (ACO) emerge each year aiming to improve care
quality while controlling rising health care costs. This cross-sectional study
examined whether ACO arrangements within a Preferred Provider Organization and a
Health Maintenance Organization (HMO) effected patient experience. A modified
Consumer Assessment of Healthcare Providers and Systems ACO survey was used to
assess care domain differences overall and by product. The association between
ACO and non-ACO populations and items in each significant care domain, flu
vaccination, and delayed and emergency department care are explored using
multivariable logistic regression. Accountable care organizations patients were
more likely to report it was easy to get a specialist appointment (adjusted odds
ratio [AOR], 1.54; 95% CI = 1.11-2.13), less likely to report visiting the
emergency department for care (AOR, 0.70; 95% CI = 0.55-0.90) and communicating
with their provider using technology (AOR, 0.79; 95% CI = 0.65-0.96). Reported
experience differed for Access to Specialists between ACO and
non-ACO groups among overall and HMO respondents (79.4% vs 74.7% and 79.9% vs
75.5%, P < .05, respectively). The ACO patient experience
was not substantially better. Strategies incorporating satisfaction and
experience, whether linked to contracts or not, should be encouraged given ACOs
goal to optimize patient care. Survey instruments must be improved to capture
nuances of provider care and patient bond that is vital in ACO integrated
systems.
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Affiliation(s)
- Joanne M Graham
- Health Innovation and Pilot Performance, Health Plan Research and Administration Division, California Public Employees' Retirement System, Sacramento, CA, USA
| | - David W Cowling
- Health Innovation and Pilot Performance, Health Plan Research and Administration Division, California Public Employees' Retirement System, Sacramento, CA, USA
| | - Hui Zhang
- Health Innovation and Pilot Performance, Health Plan Research and Administration Division, California Public Employees' Retirement System, Sacramento, CA, USA
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Barath D, Amaize A, Chen J. Accountable Care Organizations and Preventable Hospitalizations Among Patients With Depression. Am J Prev Med 2020; 59:e1-e10. [PMID: 32334954 PMCID: PMC7458155 DOI: 10.1016/j.amepre.2020.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 01/30/2020] [Accepted: 01/31/2020] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Accountable care organizations have been successful in improving quality of care, but little is known about who is benefiting from accountable care organizations and through what mechanism. This study examined variation of potentially preventable hospitalizations for chronic conditions with coexisting depression in adults by hospital accountable care organization affiliation and care coordination strategies by race/ethnicity. METHODS Data files of 11 states from 2015 State Inpatient Databases were used to identify potentially preventable hospitalizations for chronic conditions with coexisting depression by race/ethnicity; the 2015 American Hospital Association's Annual Survey was used to identify hospital accountable care organization affiliation; and American Hospital Association's Survey of Care Systems and Payment (collected from January to August 2016) was used to identify hospital Accountable care organizations affiliation and hospital-based care coordination strategies, such as telephonic outreach, and chronic care management. In 2019, multiple logistic regressions was used to test the probability of potentially preventable hospitalization by accountable care organization affiliation and race/ethnicity. The test was repeated on a subsample analysis of accountable care organization-affiliated hospitals by care coordination strategy. RESULTS Preventable hospitalizations were significantly lower among accountable care organization-affiliated hospitals than accountable care organization-unaffiliated hospitals. Lower preventable hospitalization rates were observed among white, African American, Native American, and Hispanic patients. Effective care coordination strategies varied by patients' race. Results also showed variation of the adoption of specific care coordination strategies among accountable care organization-affiliated hospitals. Analysis further indicated effective care coordination strategies varied by patients' race. CONCLUSIONS Accountable care organizations and specifically designed care coordination strategies can potentially improve preventable hospitalization rates and racial disparities among patients with depression. Findings support the integration of mental and physical health services and provide insights for Centers for Medicare and Medicaid Services risk adjustment efforts across race/ethnicity and socioeconomic status.
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Affiliation(s)
- Deanna Barath
- Department of Health Policy and Management, University of Maryland, College Park, Maryland.
| | - Aitalohi Amaize
- Department of Health Policy and Management, University of Maryland, College Park, Maryland
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland, College Park, Maryland
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